AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Human bite wounds are notoriously deceptive and are often underestimated and undertreated. While controversies regarding optimal management continue, the basic tenets of meticulous wound care are no different than those for contaminated wounds.

The goals of therapy are to prevent or appropriately treat infection and to minimize the soft tissue deformity. Recognition and early, aggressive treatment are mandatory to prevent infection and associated complications.

Approximately 10-15% of human bite wounds become infected, and this considerable infection rate is multifactorial. Patients often wait until infection is established before presenting late in the course of their injury, thus necessitating medical attention. Wounds evaluated earlier are frequently more extensive than estimated on initial examination by the inexperienced observer and are frequently managed inadequately.

The bacterial inoculum of human bite wounds is rich in oral flora, as saliva contains as many as 100,000,000 organisms per mL, representing as many as 190 different species. Moreover, most of these injuries occur on the hands, and hand wounds of any cause have a higher infection rate than similar wounds in other anatomic locations.

The possibility of transmission of disease through human bites must be considered. Human bites have been shown to transmit hepatitis B, hepatitis C, herpes simplex virus (HSV), syphilis, tuberculosis, actinomycosis, and tetanus. Evidence suggests that it is biologically possible to transmit HIV through human bites, although this is quite unlikely.

For additional information on hepatitis B and hepatitis C, see Medscape’s Hepatitis B Resource Center and Hepatitis C Resource Center.

Pathophysiology

Human bite wounds occur as 2 separate entities: clenched-fist injuries and occlusive bites.

Clenched-fist injury

Clenched-fist injuries are the most common and possess the greater clinical significance. They occur as the closed fist strikes the teeth of another individual with sufficient force to create a small wound, usually 3-8 mm in length. The injury usually occurs over the dorsal surface of the middle finger metacarpophalangeal joint of the dominant hand. Potential injuries include joint penetration, metacarpal fracture, and extensor tendon laceration. Digital nerve or digital artery injury is rare.

As the fingers extend following injury, the bacterial inoculum may be carried proximally with the extensor tendons. This makes adequate irrigation of the wound more difficult. These are the most serious human bite wounds, and they require the most aggressive treatment.

Occlusive bites

Occlusive bites occur when the teeth bite a part of the body with sufficient force to violate the integrity of the skin. Although less serious than clenched-fist injuries, those occurring on the hand must be treated with greater attention, as they have a higher infection rate than occlusive bites to other parts of the body.

Regardless of mechanism and anatomic location, the bacterial inoculum deserves special consideration because it is composed of the rich oral flora of aerobes and anaerobes. Cultures of human bite wounds are commonly polymicrobial in nature, and aerobes and anaerobes are represented almost equally. Several bacterial species produce beta-lactamase, rendering them resistant to penicillin.

Commonly isolated aerobes include Eikenella corrodens and Staphylococcus, Streptococcus, and Corynebacterium species. Staphylococcus aureus is associated with some of the most severe infections, resulting in the highest complication rates. E corrodens is a slow-growing, gram-negative bacillus frequently associated with chronic infection and abscess formation. Commonly isolated anaerobes include Bacteroides and Peptostreptococcus species.

In addition to the infection risk, the potential for transmission of life-threatening disease is also present in human bites. Hepatitis B has been transmitted through human bites, as 75% of patients with hepatitis B infection have detectable antigen in their saliva. Less likely is the transmission of HIV, although several cases in the literature suggest this mode of transmission.^{1, 2} HIV is found in the saliva of affected patients, although at lower levels than in the blood. In addition, salivary inhibitors render the virus noninfective in most cases.

Frequency

United States

Human bites are believed to be the third-most-common bite wounds, following dog and cat bites. The true frequency is difficult to estimate because the vast majority probably go unreported and because many patients do not seek medical attention.

Of those reported, approximately 60% occur in the upper extremities, while another 15% occur in the head and neck region. The remainder occur on the breasts, genitals, thighs, and other areas.

Upper extremity bites most frequently occur on the dominant extremity. Head and neck injuries most commonly occur on the ears, nose, or lips.

Mortality/Morbidity

• The morbidity of human bites is related to infection and its sequelae.
• Prior to the era of antibiotics, up to 20% of hand bites required amputation of a finger.
• While amputation is necessary only in extreme cases today, bite wound infections are common and may result in permanent functional and/or cosmetic impairment.

Sex

• Clenched-fist injuries are predominantly a wound among males, a fact attributable to their more aggressive behavior.
• Occlusive bite wounds occur with equal frequency.

Age

• Clenched-fist injuries most commonly occur between adolescence and the fourth decade of life.
• Occlusive injuries are probably most common in toddlers placed in crowded daycare centers. These bites are usually superficial and rarely become infected.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

A thorough, detailed history is necessary to facilitate communication between various health care professionals involved in the treatment of the patient and to document why the plan of care was appropriate.

When questioned as to the nature of the injury, patients often mislead the examiner out of embarrassment or fear of legal repercussion. These cases are often assault cases and are more likely to involve the judicial system. With that in mind, documentation should be clear, concise, and complete.

• Natural history of the wound
• • Circumstances surrounding the injury
  • Precipitating event or activity
  • Exact mechanism of injury
  • Time of occurrence
  • Location of occurrence
  • Whether the other party involved is known to the patient and available should testing be indicated
  • Treatment initiated prior to presentation
• Presence of signs or symptoms related to the wound
• • Pain
  • Fever
  • Swelling
  • Discharge or odor
  • Tobacco, alcohol, or recreational drug use
• Medications or allergies to medications
• Tetanus immune status
• Ability to comprehend the magnitude of injury and to cooperate with the treatment plan
• Comorbid conditions that may place the patient at a higher risk for infection or its sequelae 
• • Diabetes mellitus
  • Chronic edema of the region (eg, prior ipsilateral axillary node dissection for an upper extremity wound)
  • Prior splenectomy
  • Liver disease
  • Immunosuppression
  • Presence of a prosthetic valve or joint
  • Regional arterial or venous disease

Physical

• A thorough physical examination is necessary to evaluate the overall state of health, comorbidities, nutritional status, and mental status of the patient.
• Following the general physical examination, turn attention toward the wound. Assessment of the wound can be quite difficult and is often inaccurately or inadequately performed.
• Adequate examination of the wound may require administration of intravenous or oral pain medication to ensure patient comfort.
• Small wounds, particularly in the hands, may require extension for adequate evaluation.
• Important aspects of wound assessment
• • Location
  • Shape
  • Size
  • Type (puncture, laceration, avulsion or crush)
  • Depth of penetration
  • Drainage (quantity, character, odor)
  • Presence of a foreign body (tooth fragments, particulate matter)
  • Loss of tissue
  • Tenderness
  • Asymmetry
  • Surrounding erythema, edema, cellulitis, or crepitance
  • Neurovascular status
  • Violation of tendon, cartilage, joint spaces, or bone: This may be difficult to detect on initial examination and may require operative exploration to adequately diagnose.
  • Regional lymphadenopathy
  • Examine hand injuries through the full range of hand motions, particularly in clenched-fist injuries
  • Although not standard in all centers, the following guidelines for wound documentation in cases of assault have been established by the American Board of Forensic Odontology:³
  • • Photographic documentation
    • Wound diagram, including notation of arch pattern and intercanine width
    • Bite mark impressions
    • Swabbing of the wound for tissue typing

Causes

• Aggressive behavior, often in combination with alcohol (the cause of most clenched-fist injuries)
• Rough sexual play or sexual assault
• Domestic violence
• Child abuse
• Occupational injury to dental personnel
• Seizure-related tongue lacerations
• Nose-biting (punishment for adultery in several cultures⁴)
• Accidents during sporting events
• Aggressive play of children in daycare centers
• Self-inflicted wounds in persons who are emotionally disturbed or mentally handicapped

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• No laboratory studies are required unless bacteremia or sepsis is suspected.
• If indicated, draw appropriate baseline viral titers from the patient and the assailant.

Imaging Studies

• Radiography may be useful, particularly in hand injuries or over bone, to reveal fractures, foreign bodies (tooth fragment), or air within a joint.
• Radiography of chronic wounds may reveal underlying osteomyelitis.

Other Tests

• Routine culture of all human bite wounds is unnecessary because they are costly, demonstrate no growth in more than 80% of cases, and rarely alter first-line therapy.
• Wounds subsequently manifesting signs of infection often have bacteriologic profiles differing from the initial cultures.
• Wound cultures are indicated in wounds manifesting signs of infection (eg, cellulitis, swelling, purulence) and in wounds not showing clinical improvement despite seemingly appropriate antimicrobial therapy.
• Obtain and grow aerobic and anaerobic cultures for 7-10 days to identify slow-growing pathogens. This allows quantification and identification of bacterial species and their antibiotic susceptibilities. If possible, obtain cultures prior to the initiation of antimicrobial therapy.

Procedures

• Meticulous wound care is the cornerstone of human bite wound management.
• Copious irrigation decreases the incidence of wound infection.  
• • Use isotonic sodium chloride solution, dilute povidone-iodine (Betadine), or dilute hydrogen peroxide to thoroughly cleanse the wound.
  • Cleansing is best performed with a 10-mL syringe with an 18-gauge angiocatheter attached.
  • Take care to avoid injection of the tissues and to prevent additional trauma.
• Careful debridement of devitalized tissue, particulate matter, and clot is also necessary to reduce the infection risk and to improve the cosmetic result.
• Faster wound healing and better scarring result from clean, surgically created wound margins.
• Wound closure is a source of controversy in the management of patients with human bite wounds.  
• • In general, do not close hand wounds, puncture wounds, infected wounds, and wounds more than 12 hours old. Allow such wounds to heal by secondary intention. They may be closed secondarily or revised at a later date.
  • Head and neck wounds, being in a cosmetically sensitive area, may be closed if they are less than 12 hours old and not obviously infected. These wounds have been closed with a low incidence of infection, probably because of excellent blood supply and infrequency of edema.
  • The following points deserve specific mention:  
  • • Antibiotic prophylaxis is mandatory in these patients.⁵
    • Perform closure in a simple, interrupted fashion, avoiding layered closure with buried sutures.
    • The objective is to provide wound edge approximation that is not watertight and still allow for drainage.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Although rare, human bites have been shown to transmit Clostridium tetani. Assess all patients for tetanus immune status and update as appropriate. Erring on the side of caution when deciding to administer tetanus toxoid or tetanus immune globulin is best. These wounds are often several days old and are heavily contaminated or even infected upon first presentation. Bites with no significant skin penetration (abrasions or contusions) require no further care.

• Human bite wounds at risk for transmission of life-threatening disease require individualization of therapy.
• A fully informed patient may make appropriate choices regarding viral prophylaxis when risks and benefits are clearly explained and understood.
• Hepatitis B
• • Offer the patient a single dose of hepatitis B immunoglobulin (HBIG) and an accelerated course of hepatitis B vaccine with doses at 0, 1, and 2 months, unless the patient is known to be immune.
  • If the assailant's hepatitis B status is unknown but is considered high risk and the assailant is unavailable for testing, offer an accelerated course of the hepatitis B vaccine to the patient.
  • If the assailant's status is unknown but is considered low risk and the assailant is unavailable for testing, the accelerated course of the hepatitis B vaccine may be offered to the patient with the understanding that the likelihood of disease transmission is low.
• Human immunodeficiency virus
• • If the assailant is known to carry HIV or is considered high risk but unavailable for testing, the Centers for Disease Control and Prevention (CDC) recommends that patients exposed to potentially infectious fluids be offered zidovudine and, possibly, lamivudine chemoprophylaxis.
  • Draw a baseline specimen from the patient to determine preexposure HIV status.
  • Retest the patient at 3 and 6 months.
  • Failure to convert to HIV-positive status at 6 months makes transmission highly unlikely.

Surgical Care

• Surgical intervention is frequently necessary, ranging from simple wound exploration and debridement to repair of complex structures under magnification.
• Certain patients (eg, children, persons who are emotionally unstable, persons who are mentally handicapped) may require surgical exploration under anesthesia to adequately examine the wound.
• Indications for surgical intervention
• • Severe soft tissue infection
  • Abscess
  • Joint penetration
  • Underlying fracture
  • Tendon laceration
  • Osteomyelitis
  • Tenosynovitis
  • Septic arthritis
  • Neurovascular compromise or injury to a complex structure
  • Foreign body

Consultations

A multidisciplinary approach can lead to maximum patient benefit in certain circumstances.

• Refer to a hand surgeon any hand injury with suspicion of tendon injury, fracture, joint space violation, retained foreign body, injury to nerve or vessel, or significant tissue loss. These have a significant risk for permanent disability and should be referred to a hand therapist.
• Refer to a plastic surgeon any head or neck wound with suspicion of violation of cartilage, retained foreign body, or injury to nerves, vessels, or other complex structure. Also refer to a plastic surgeon any wounds that have caused significant tissue loss creating difficult closure.

Activity

After initial immobilization of hand injuries in a position of function and elevation, provide instruction regarding resumption of activity.

• In general, early mobilization (ie, 48-72 h postinjury), once improvement is noted, prevents one of the most common and difficult complications of hand injuries: the stiff joint.
• Continue elevation until edema resolves.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The question of which patients require antibiotic therapy is a matter of considerable debate. Antibiotics cannot avert or cure infections in the face of poor wound care, reflecting the importance of meticulous treatment of the wound as the cornerstone of therapy. In regard to antibiotic therapy, it is best to err on the side of caution because the risks of antibiotic therapy are minimal, while the potential complications of bite wound infections are considerable.

In general, superficial noninfected wounds involving sites other than the hand that are evaluated early in the compliant patient without significant comorbidities may be treated without antibiotics if the wound is left open to heal by secondary intention.

Wounds of the hand, infected wounds, and wounds of the head and neck closed primarily mandate antibiotic therapy.

Wounds treated on an outpatient basis may be treated with oral antibiotics, whereas wounds requiring admission to the hospital should be treated with intravenous antibiotics.

Prophylaxis in the noninfected wound should be continued for 5-7 days, whereas therapeutic antibiotics should be administered for 10-14 days.

Selection of the appropriate antibiotic involves multiple factors, including culture results if obtained and available, drug sensitivities, patient age, drug interactions, expected compliance, and renal and hepatic function.

Drug Category: Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Drug Name	Doxycycline (Doryx, Vibramycin, Vibra-Tabs)
Description	Alternative for oral therapy in the penicillin-allergic patient. Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult Dose	100 mg PO bid
Pediatric Dose	<8 years: Not established >8 years: 2-4 mg/kg/d PO divided q12h
Contraindications	Documented hypersensitivity; severe hepatic dysfunction; lactation
Interactions	Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Pregnancy	D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions	Caution in patients who are cachectic or debilitated and in hepatic or renal disease; photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines

Drug Name	Ceftriaxone sodium (Rocephin)
Description	Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins. Once-daily IM dosing may benefit the noncompliant patient. Also may be used as an IV antibiotic for patients admitted to the hospital.
Adult Dose	1 g IV/IM qd
Pediatric Dose	50 mg/kg/d IV/IM qd
Contraindications	Documented hypersensitivity
Interactions	Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin

Drug Name	Cefoxitin sodium (Mefoxin)
Description	Second-generation cephalosporin indicated for gram-positive cocci and gram-negative rod infections. Infections caused by cephalosporin- or penicillin-resistant gram-negative bacteria may respond to cefoxitin.
Adult Dose	1-2 g IV q4-8h
Pediatric Dose	25-50 mg/kg/d IV divided q6h
Contraindications	Documented hypersensitivity
Interactions	Probenecid may increase effects of cefoxitin; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in patients with previously diagnosed colitis

Drug Name	Ampicillin sodium and sulbactam (Unasyn)
Description	Drug combination of beta-lactamase inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens.
Adult Dose	1.5 (1 g ampicillin + 0.5 g sulbactam) to 3.0 g (2 g ampicillin + 1 g sulbactam) IV/IM q6-8h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin
Pediatric Dose	<12 years: Not established >12 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction

Drug Name	Ticarcillin disodium and clavulanic acid (Timentin)
Description	Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active growth.
Adult Dose	3.1 g IV q6h
Pediatric Dose	<12 years: Not established >12 years: Administer as in adults
Contraindications	Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with oral penicillin during acute stage
Interactions	Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients diagnosed with hepatic insufficiencies; perform urinalysis, BUN, and creatinine determinations during therapy, and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Some patients require hospitalization for surgical intervention, intravenous antibiotic administration, and observation.
• If surgery is not initially performed, admitting the patient allows prompt surgical intervention if no improvement is noted or the clinical situation deteriorates.
• Indications for hospitalization
• • Any patient with an injury severe enough to require operative exploration should be observed overnight postoperatively. Some may well require a longer stay, but this is dictated by the specific clinical situation.
  • Any patient with systemic manifestations of infection such as fever, chills, or elevated white blood cell count
  • Patients with significant comorbidities
  • Patients with failure to improve with initial outpatient management
  • Patients with a high likelihood of noncompliance (eg, persons who are emotionally disturbed, mentally handicapped, or homeless; persons with chronic alcoholism)
  • Patients with infected hand wounds

Further Outpatient Care

• Patients evaluated early, without evidence of infection, and without hand wounds may be treated on an outpatient basis without antibiotics.
• • Patients must return within 48-72 hours for reassessment.
  • The development of any signs or symptoms of infection indicate the need to seek immediate medical attention.
• Patients with mild-to-moderate infections or hand wounds without infection may also be treated on an outpatient basis with oral antibiotics if they are likely to be compliant with the overall treatment plan.
• • Patients must return within 24-48 hours for reassessment.
  • They must immediately seek medical attention if their clinical condition deteriorates.

In/Out Patient Meds

• Antibiotics administered initially or during hospitalization should be continued for the length of time determined by the treating physician.

Complications

• Cosmetic deformity resulting from wound contraction
• Permanent hand disability secondary to stiffness and/or chronic pain
• Tenosynovitis
• Osteomyelitis
• Septic arthritis
• Abscess formation
• Amputation (rare)
• Transmission of disease

Prognosis

• Prognosis is excellent in the compliant patient who promptly seeks medical attention following injury.

Patient Education

• Patients must clearly understand the signs and symptoms of wound infection for which they must return for immediate reevaluation. These include but are not limited to fever, odor, drainage, purulence, swelling, cellulitis, warmth, pain, and decreased mobility.
• Patients must clearly understand the importance of early and regular follow-up care for this seemingly minor injury.
• Patients must clearly understand the rationale for providing antibiotics and the importance of compliance with this recommendation.
• Patients must clearly understand the potential complications that may develop even with complete compliance with the care plan.
• Patients should understand that wound revision for cosmetic or functional purposes might be desirable at a later date.
• For excellent patient education resources, visit eMedicine's Bites and Stings Center and Infections Center. Also, see eMedicine's patient education articles Human Bites and Tetanus.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• These cases are more likely to involve the judicial system, to have an increased likelihood of infection, and to have a significant rate of permanent functional or cosmetic deformity.
• It is extremely important that the chart reflect the following:
• • An adequate initial evaluation
  • An appropriate care plan
  • That the patient was counseled regarding potential complications and importance of early and regular follow-up care
• Most jurisdictions require medical professionals to report suspected child abuse.⁶

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

1. Khajotia RR, Lee E. Transmission of human immunodeficiency virus through saliva after a lip bite. Arch Intern Med. Sep 8 1997;157(16):1901. [Medline].
2. Vidmar L, Poljak M, Tomazic J, Seme K, Klavs I. Transmission of HIV-1 by human bite. Lancet. Jun 22 1996;347(9017):1762. [Medline].
3. Freeman AJ, Senn DR, Arendt DM. Seven hundred seventy eight bite marks: analysis by anatomic location, victim and biter demographics, type of crime, and legal disposition. J Forensic Sci. Nov 2005;50(6):1436-43. [Medline].
4. Okimura JT, Norton SA. Jealousy and mutilation: nose-biting as retribution for adultery. Lancet. Dec 19-26 1998;352(9145):2010-1. [Medline].
5. Presutti RJ. Bite wounds. Early treatment and prophylaxis against infectious complications. Postgrad Med. Apr 1997;101(4):243-4, 246-52, 254. [Medline].
6. Welbury RR, Murphy JM. The dental practitioner's role in protecting children from abuse. 3. Reporting and subsequent management of abuse. Br Dent J. Feb 14 1998;184(3):115-9. [Medline].
7. Bunzli WF, Wright DH, Hoang AT, Dahms RD, Hass WF, Rotschafer JC. Current management of human bites. Pharmacotherapy. Mar-Apr 1998;18(2):227-34. [Medline].
8. Chidzonga MM. Human bites of the face. A review of 22 cases. S Afr Med J. Feb 1998;88(2):150-2. [Medline].
9. Corabianu O, Laredo JD, Woimant F, Haguenau M. Hazards of tongue-biting: Streptococcus oralis bacteraemia and vertebral osteomyelitis following a grand mal seizure. J Neurol. Jan 1998;245(1):47-9. [Medline].
10. Donkor P, Bankas DO. A study of primary closure of human bite injuries to the face. J Oral Maxillofac Surg. May 1997;55(5):479-81; discussion 481-2. [Medline].
11. Epstein JB, Scully C. Mammalian bites: risk and management. Am J Dent. Jun 1992;5(3):167-71. [Medline].
12. Goldstein EJ, Citron DM, Hudspeth M, Hunt Gerardo S, Merriam CV. In vitro activity of Bay 12-8039, a new 8-methoxyquinolone, compared to the activities of 11 other oral antimicrobial agents against 390 aerobic and anaerobic bacteria isolated from human and animal bite wound skin and soft tissue infections in humans. Antimicrob Agents Chemother. Jul 1997;41(7):1552-7. [Medline].
13. Goldstein EJ, Citron DM, Hudspeth M, Hunt Gerardo S, Merriam CV. Trovafloxacin compared with levofloxacin, ofloxacin, ciprofloxacin, azithromycin and clarithromycin against unusual aerobic and anaerobic human and animal bite-wound pathogens. J Antimicrob Chemother. Mar 1998;41(3):391-6. [Medline].
14. Griego RD, Rosen T, Orengo IF, Wolf JE. Dog, cat, and human bites: a review. J Am Acad Dermatol. Dec 1995;33(6):1019-29. [Medline].
15. Kelly IP, Cunney RJ, Smyth EG, Colville J. The management of human bite injuries of the hand. Injury. Sep 1996;27(7):481-4. [Medline].
16. Ruskin JD, Laney TJ, Wendt SV, Markin RS. Treatment of mammalian bite wounds of the maxillofacial region. J Oral Maxillofac Surg. Feb 1993;51(2):174-6. [Medline].
17. Ulione MS, Dooling M. Preschool injuries in child care centers: nursing strategies for prevention. J Pediatr Health Care. May-Jun 1997;11(3):111-6. [Medline].

Article Last Updated: Mar 27, 2008